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Dear unborn baby,
Please consider holding your poo in until after you are born. The big people on the outside get very stressed about your poo and will want to change the way you are birthed if they find any evidence that you have failed to keep it in. Your mother will be told that you are in danger, and will be strapped to a CTG monitor. This will: reduce her ability to help you through her pelvis by moving; prevent her from using water to relax; and increase your chance of being born by c-section. Your mother will also have her time limits for labour tightened up. This may lead to labour being induced or augmented which will put both of you at risk of further interventions. You will be expected to get through your mother’s vagina quickly and if you take too long you will be pulled out with medical instruments. As you are being born you will have plastic tubes pushed into your nose, mouth and throat to suction your airway. Once born, your cord will be cut immediately and you will be given to a paediatrician who may also put tubes into your nose and mouth. You will only be given back to your mother once you are crying effectively. You may not feel like breastfeeding after being suctioned – don’t worry, this is normal. In the first 24 hours after birth you will be disturbed regularly to have cold items put onto your skin to monitor your temperature, breathing and heart rate. In some hospitals you will be taken away from your mother to be observed in nursery. So, if at all possible do your mother and yourself a favour and try to hold on to your poo until after you are born.
Meconium facts
Meconium is a mixture of mostly water (70-80%) and a number of other interesting ingredients (amniotic fluid, intestinal epithelial cells, lanugo, etc.). Around 15-20% of babies are born with meconium stained liquor.
There are three reasons (theoretically) that a baby will open his/her bowels before birth (Unsworth & Vause 2010):
- Because their digestive system has reached maturity and the bowel has begun working. This is the most common reason and 30-40% of post-term babies will have passed meconium in-utero.
- Because their cord or head is being compressed (during labour) ie. a vagally mediated gastrointestinal peristalsis – the same reflex which causes variable heart rate decelerations. This is a normal physiological response and can happen without fetal distress.
- Fetal distress resulting in hypoxia. However the exact relationship between fetal distress and meconium stained liquor is uncertain. The theory is that intestinal ischaemia relaxes the anal sphincter and increases gastrointestinal peristalsis = passage of meconium. However, fetal distress can be present without meconium, and meconium can be present without fetal distress.
Meconium alone cannot be relied on as an indication of fetal distress: “… meconium passage, in the absence of other signs of fetal distress, is not a sign of hypoxia…”(Unsworth & Vause 2010). An abnormal heart rate is a better predictor of fetal distress; and an abnormal heart rate + meconium provides an even better indication that a baby may be in trouble. In addition, thick meconium rather than thin meconium is associated with complications. Despite this, babies who are known to have passed meconium (of any variety) without any other risk factors are treated as if they are in imminent danger. I am guessing this is because if a previously unstressed baby becomes hypoxic during labour it may result in the dreaded MAS.
Meconium Aspiration Syndrome (MAS)
MAS is the major concern when meconium is floating about in the amniotic fluid. It is an extremely rare complication – around 2-5% of the 15-20% of babies with meconium stained liquor will develop MAS (Unsworth & Vause 2010). Of the 2-5% of the 15-20%, 3-5% of babies will die. OK enough %s of %s – basically it is very rare but can be fatal.
MAS occurs when the baby inhales meconium stained liquor during labour, birth or immediately following birth. You can see a simple explanation of MAS in utero (where it usually happens) here. However this animation does not detail why aspiration might take place.
Babies make shallow breathing movements during pregnancy. Breathing movements slow down in response to prostaglandins before birth. During labour and birth it is very unlikely that a baby will inhale liquor (and any meconium in it). This will only happen if the baby becomes extremely hypoxic and begins to gasp in utero in an attempt to get oxygen. So, meconium alone is not a problem. Meconium + a hypoxic baby = the possibility of MAS (Davies & MacDonald 2008).
Bizarre Practice
So you would think that the sensible thing to do if a baby has passed meconium (for whatever reason) is to create conditions that are least likely to result in hypoxia and MAS. This is where I get confused because common practice is to do things that are known to cause hypoxia, for example:
- Inducing labour if the waters have broken (with meconium present) and there are no contractions or if labour is ‘slow’ in an attempt to get the baby out of the uterus quickly.
- Performing an ARM (breaking the waters) to see if there is meconium in the waters when there are concerns about the fetal heart rate.
- Creating concern and stress in the mother which can reduce the blood flow to the placenta.
- Directed pushing to speed up the birth.
- Having extra people in the room (paediatricians), bright lights and medical resus equipment which may stress the mother and reduce oxytocin release.
- Cutting the umbilical cord before the placenta has finished supporting the transition to breathing in order to hand the baby to the paediatrician.
Suctioning the baby’s airways?
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I am unsure whether this is common practice or not. Evidence based clinical guidelines generally recommend NOT suctioning a baby’s airways unless they are unresponsive, floppy and require resuscitation. And then only to do so using a laryngoscope so that you can see what you are doing. Guidelines: NICE guideline, Resuscitation Council UK, more guidelines. Key research: Wiswell et al. 2000, Vain et al. 2004. So, I would assume that practice would be informed by these guidelines.
However, on my frequent youtube birth-surfing trips I encounter suctioning of babies often (without meconium present). Both ‘on the perineum’ and following birth. I have seen this being done at hospital births, homebirths, and even unassisted births. You can see an extreme version of suctioning in this previous post. A more conservative method using the suction bulb pictured above seems to figure in a lot of the homebirths on youtube. So, I am guessing that this is a common routine practice in the US. Therefore, I feel obliged to reiterate why this is not only invasive and pointless but may also be detrimental. Suctioning at birth does not reduce the risk of MAS but can:
- Cause the baby to gasp ie. inhale deeply which is exactly what you are wanting to avoid with meconium stained liquor (Roggensack et al. 2009).
- Lower the baby’s heart rate for up to 20 minutes (vagal bradycardia) (Waltman 2004).
- Interfere with the initiation of breastfeeding (Killion 2000)
- Cause tissue trauma (Davies & MacDonald 2008).
In addition I am guessing it is not a very pleasant experience/welcome for the baby. Anyway, the birth process takes care of the mucous and amniotic fluid in the baby’s airways. As you can see from the photo below the airways clear as the head is born and while waiting for the next contraction – the chest is compressed, squeezing the fluid out and gravity helps it to drain. Babies born by c-section miss out on this and are more likely to end up with problems associated with fluid in the airways and stomach.
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From Navelgazing Midwife's blog (hover on photo for link)
Suggestions
All babies deserve to have the least stressful arrival possible. It is even more important that a baby who has passed meconium does not become stressed and hypoxic during labour and birth because it could lead to MAS. The following suggestions apply to all births including when there is meconium stained liquor.
- Avoid an ARM during labour so that any meconium present is not known about until the membranes rupture spontaneously (hopefully this will happen after much of the labour is complete). If there is meconium present it will remain well diluted and the amniotic fluid will protect the baby from compression during contractions.
- Ensure that the mother knows meconium is a variation and not necessarily a complication.
- Create a relaxing birth environment.
- Avoid any interventions that are associated with fetal distress – ARM, syntocinon/pitocin, directed pushing.
- Offer continuous CTG monitoring if the meconium is thick – or if the meconium is thin and there are other risk factors (eg. pre-term).
- If the meconium is thin and there are no other risk factors offer intermittent fetal heart rate auscultation as usual.
- In hospital do not allow others into the room unless the mother wants them there. If there is a policy to have a paediatrician present they can wait outside the room to be called if needed.
- To assist with airway clearing encourage a slow birth of the baby’s head in a position that allows drainage of the airways (ie. mother not lying on her back). Do not pull the baby out – allow the mother and baby to wait for the next contraction whilst the airways clear themselves.
- Once baby is born leave the umbilical cord intact until it has stopped pulsing to allow a gentle transition to breathing.
- Keep baby skin to skin with mother following birth.
- Encourage the mother to let you know if she is concerned about her baby in any way over the next 24 hours (eg. feeling hot, noisy breathing, etc.)
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